Protein-energy wasting and nutritional supplementation in patients with end-stage renal disease on hemodialysis

doi:10.1016/j.clnu.2016.06.007

Clinical Nutrition

Volume 36, Issue 3, June 2017, Pages 663-671

https://doi.org/10.1016/j.clnu.2016.06.007 Get rights and content

Summary

Background & aims

Protein-Energy Wasting (PEW) is the depletion of protein/energy stores observed in the most advanced stages of Chronic Kidney Disease (CKD). PEW is highly prevalent among patients on chronic dialysis, and is associated with adverse clinical outcomes, high morbidity/mortality rates and increased healthcare costs. This narrative review was aimed at exploring the pathophysiology of PEW in end-stage renal disease (ESRD) on hemodialysis. The main aspects of nutritional status evaluation, intervention and monitoring in this clinical setting were described, as well as the current approaches for the prevention and treatment of ESRD-related PEW.

Methods

An exhaustive literature search was performed, in order to identify the relevant studies describing the epidemiology, pathogenesis, nutritional intervention and outcome of PEW in ESRD on hemodialysis.

Results and conclusion

The pathogenesis of PEW is multifactorial. Loss of appetite, reduced intake of nutrients and altered lean body mass anabolism/catabolism play a key role. Nutritional approach to PEW should be based on a careful and periodic assessment of nutritional status and on timely dietary counseling. When protein and energy intakes are reduced, nutritional supplementation by means of specific oral formulations administered during the hemodialysis session may be the first-step intervention, and represents a valid nutritional approach to PEW prevention and treatment since it is easy, effective and safe. Omega-3 fatty acids and fibers, now included in commercially available preparations for renal patients, could lend relevant added value to macronutrient supplementation. When oral supplementation fails, intradialytic parenteral nutrition can be implemented in selected patients.

Introduction

In patients with Chronic Kidney Disease (CKD), especially in those with End-Stage Renal Disease (ESRD, or CKD stage 5), a progressive depletion of protein and/or energy stores is often observed [1]. The term “Protein-Energy Wasting” (PEW) has been suggested to describe this clinical condition, which has high prevalence rates (up to 50–75% of patients with CKD stages IV–V), and is closely associated with both increased morbidity/mortality risk and worsened quality of life [1]. Inflammation often co-exists and, together with muscle wasting, confers a specific pattern to CKD-related PEW, which distinguishes this clinical entity in respect to other forms of malnutrition [1], [2], [3].

In ESRD two important issues must be addressed to implement tailored nutritional interventions against PEW, namely: 1) a thorough understanding of the pathogenesis and 2) a timely diagnosis and a close monitoring of nutritional status [1], [2], [3]. Hence, in this narrative review we aimed firstly at exploring the pathophysiology of PEW in ESRD on hemodialysis. Subsequently, we describe the main aspects of nutritional status evaluation, intervention and monitoring in this clinical setting. Finally, we discuss the current approaches reported in literature, consensus and guidelines for the prevention and treatment of ESRD-related PEW.

Section snippets

Methods

An exhaustive review of English language literature was performed to identify all relevant articles describing the epidemiology, pathogenesis, nutritional intervention and outcome of PEW in ESRD on hemodialysis. To this purpose, we searched, PubMed, EMBASE™, CINHAL, Web of Science and Cochrane databases for relevant articles. Related search terms were used as follow: “anthropometry”, “chronic kidney disease”, “dietary fiber”, “end stage renal disease”, “exercise”, “guidelines”, “hemodialysis”,

Pathophysiology of PEW in ESRD on hemodialysis

In renal patients, PEW is characterized by loss of protein and energy stores associated with multiple metabolic derangements, most of which are peculiar of CKD [1], [2], [3]. Several metabolic and clinical factors (Table 1) may negatively affect nutritional status and lean body mass [3], [4], leading to frailty [5]. Apart from an inadequate spontaneous nutrient intake, several other factors such as metabolic acidosis, insulin resistance, chronic inflammation, intestinal dysbiosis, infection and

Assessment of nutritional status in CKD/ESRD on hemodialysis

The available recommendations for the assessment of nutritional status in CKD/ESRD patients are toward an integrated approach combining the evaluation of body mass and anthropometric parameters, and biochemistry and dietary intake assessment [1], [2], [13], [14]. The International Society of Renal Nutrition and Metabolism (ISRNM) recommends that the diagnosis of PEW be established by the presence of at least one criterion in three out of four categories of nutritional variables [1] (Table 4).

Nutritional approach to PEW in ESRD on hemodialysis

a)Targets for nutritional support in ESRD on hemodialysis

Current guidelines and expert consensus recommend at least 1.1 g of protein/kg of ideal body weight per day for stable hemodialysis patients [1], [2], [13], [14]. Higher protein intakes are suggested compared to the minimum recommended for the healthy population (0.8/kg/day), since hemodialysis may lead to protein and amino acid losses. An energy intake of 35 kcal/kg ideal body weight per day, adjusting for age and the level of physical

Special nutrients for nutritional supplementation in ESRD

a)
Fiber: Despite growing evidence on the favorable effects of dietary fiber intake in CKD/ESRD patients, the optimal amount of fiber intake for this population is not yet defined [36]. However, according to the NHANES III data, the CKD population has a lower fiber intake than that recommended for the healthy population (15.4 g/day versus 25–30 g/day respectively) [37]. Dietary fiber supplementation may reduce plasma levels of some protein-bound uremic toxins typically derived from the gut, such

The influence of life-style: physical activity and exercise

Physical functioning (defined as the ability to perform activities of daily living) and exercise capacity are seriously reduced in patients with CKD, particularly in patients with ESRD on hemodialysis, when compared to healthy individuals [44], [45], [46]. A sedentary lifestyle is considered a modifiable risk factor for the development of PEW among ESRD patients and, apart from the consequent skeletal muscle hypotrophy and loss of strength, it may cause further increase in the cardiovascular

Hemodialysis related factors

An adequate hemodialysis dose delivery is needed to preserve nutritional status of ESRD patients. However, the increase of hemodialysis frequency to daily treatments is not associated with any further improvement in nutritional status [1]. As a matter of fact, daily hemodialysis was able to reduce the extracellular body water without positively modifying nutritional variables in ESRD patients [48]. Moreover, although overnight hemodialysis was associated with increased protein intake, no

Management of comorbidities

Patients with CKD/ESRD often have many comorbidities that negatively impact on nutritional status. In particular, diabetic patients have a higher incidence of PEW than non-diabetics, probably because of the negative role played by insulin resistance on protein muscle metabolism [8]. Therefore, adequate management of diabetes and insulin resistance is important in the prevention of PEW in hemodialysis patients [1]. Patients with CKD also often suffer from disorders of the gastrointestinal tract,

Conclusion

Patients undergoing maintenance hemodialysis are at high risk for developing PEW. Thus, regular and careful assessment of nutritional status is warranted, with the purpose of establishing an early diagnosis of PEW. This condition is frequently observed in the ESRD population, and is associated with increased mortality risk. Different nutritional approaches are currently available to prevent and treat PEW, and they should be carefully individualized. Intradialytic nutritional administration,

Conflict of Interest

The authors have no conflicts to declare.

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ReviewProtein-energy wasting and nutritional supplementation in patients with end-stage renal disease on hemodialysis

Summary

Background & aims

Methods

Results and conclusion

Introduction

Section snippets

Methods

Pathophysiology of PEW in ESRD on hemodialysis

Assessment of nutritional status in CKD/ESRD on hemodialysis

Nutritional approach to PEW in ESRD on hemodialysis

Special nutrients for nutritional supplementation in ESRD

The influence of life-style: physical activity and exercise

Hemodialysis related factors

Management of comorbidities

Conclusion

Conflict of Interest

Am J Kidney Dis

Kidney Int

Clin Nutr

Clin Nutr

Kidney Int

Kidney Int

Kidney Int

J Ren Nutr

J Ren Nutr

Am J Kidney Dis

Am J Clin Nutr

J Ren Nutr

Semin Nephrol

Am J Kidney Dis

Am J Kidney Dis

Clin Nutr

J Am Coll Cardiol

J Ren Nutr

Kidney Int

J Ren Nutr

Kidney Int

Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by the International Society of Renal Nutrition and Metabolism

Kidney Int

Diets and enteral supplements for improving outcomes in chronic kidney disease

Nat Rev Nephrol

Latest consensus and update on protein-energy wasting in chronic kidney disease

Curr Opin Clin Nutr Metab Care

Mechanisms of muscle wasting in chronic kidney disease

Nat Rev Nephrol

Review
Protein-energy wasting and nutritional supplementation in patients with end-stage renal disease on hemodialysis